Patient Registration Form

To speed up the process please fill this form prior to your arrival.

Patient's Full Name (This must be your legal name as on your birth certificate or passport)*

Known As

Address*

DOB

Sex

NHI Number

Phone Number

Work Number

Mobile

I CONSENT FOR MY MEDICAL INFORMATION TO BE SENT/RECEIVED ELECTRONICALLY/EMAIL.*

YesNo

Email Address*

CURRENT GP:*

Referring Doctor if different from above:

ALLERGIES

Medical Insurance Company:

Ethnic Group

Occupation

NZ Citizen/Resident*

YesNo

NZ 2 Year Work Permit*

YesNo

I agree to accept charges on overdue accounts, and to accept charges for all reasonable costs incurred in recovering outstanding amounts, including debt collection and legal fees, should this be applicable.*

YesNo

* Required.

Our Vision

“To provide excellent healthcare to our gynaecology and fertility patients while aiming to be respectful to their needs with open and timely communication.”